Wednesday, November 26, 2008

The ACP Advocate Blog will be taking a break for the rest of this holiday week, resuming with new commentary on Monday, December 1.

In the spirit of Thanksgiving, a day when most of us will be dining on a smorgasbord of different foods, you might want to sample a variety of intriguing blog postings I've come across recently:

Niko Karvounis has a two part posting on the Health Beat blogon how "we can create a health care system that nurtures primary care physicians instead of breaking their spirits."

Scott Henley debunks "Five Health Care Myths" in the Wall Street Journal's Health Blog, including the myth that the U.S. has the best health care in the world. (Interestingly, ACP debunked the same myth in a position paper published this past January 1 in the Annals of Internal Medicine.)

And John Goodman writes in the Health Affairs blogabout how the best features of candidate Obama's, McCain's, and Romney's health plans could be combined into a single plan. He argues that Obama actually needs to incorporate key features of his Republican rivals' plans to be successful.

Tuesday, November 25, 2008

David Harlow, writing in HealthBlawg says that recent news on the medical home is good. He cites a post by Arnold Milstein in the Health Affairs blog on "four primary care physician-led practices with average or above-average quality scores whose care enables their patients to consume 15-20% less total payer spending per year on a risk-adjusted basis than patients being treated by regional peers. Mobilizing impressive business ingenuity, they achieved this result in a U.S. payment environment that typically punishes physicians who invest to prevent costly near-term health crises."

(To learn more about the patient-centered medical home, go to ACP's new PCMH web page, a comprehensive collection of information, resources and demonstration projects to assist in planning for a complete patient-centered medical home.)

But Harlow raises an important caveat: the viability of medical homes assume a sufficient supply of primary care physicians. He quotes the following from the New York Times:

"A growing shortage of doctors willing to practice general medicine has left some [provider networks] desperate for qualified candidates and, in the long term, stands as a major obstacle to overhauling the nation's health-care system ...

Almost all changes under consideration include a central role for what used to be known as the family doctor - today generally an internist or family practitioner - who can save the system money ...

Although such primary-care doctors were once the cornerstone of American medicine, their numbers have dwindled as younger doctors have been drawn to specialty fields by money and the lure of new technology. So today ... a rising demand is confronting a declining supply."

Here's the kicker. The New York Times article was published 15 years ago, when the Times reported that in 1992 "only 14.6 percent of medical students decided to go into general medicine, an all-time low." Last month, the Journal of the American Medical Association reported that only two percent of fourth year medical students plan to go into general internal medicine.

We've known for a decade and a half that primary care is in trouble, and we also know what needs to be done about it (starting with better reimbursement), but there has been enormous political and institutional resistance to doing more than token measures.

This time around, policymakers have to get serious about fixing the problem. The patient-centered medical home has enormous potential to refocus health care around the relationship between primary care physicians and patients - supported by better reimbursement and health information systems to achieve the best possible results. The hope, of course, is that the PCMH will also make primary care more attractive and viable.

But we also need comprehensive reforms to provide immediate, sustained, and sufficient increases in reimbursement to general internists and other primary care physicians, reduce the "hassles" of practice, re-orient medical education around primary care, and allow medical students who select primary care to graduate debt-free.

Otherwise, we can build the loveliest of medical homes, but no doctors will be there when the patients arrive.

Today's questions: What do you think needs to be done to overcome decades of resistance to meaningful reforms to support primary care? And do you see the patient-centered medical home as being part of the solution?

Friday, November 21, 2008

A recurring theme on the ACP Advocate blog is the frustration internists have with paperwork. The "Happy Hospitalist" writes, "I could double or triple the number of patients I see if my daily reality wasn't controlled by third party rules and regulations that require me to document thousands of words in thousands of key places thousands of times a day." Dr. Jay Larson says that "Increased non-clinical paper work for primary care physicians is one of 3 major reasons medical students decide to choose a different career than general internal medicine." He notes that over 95% of the physicians in the Physicians Foundation survey reported increased non-clinical paper work over the past 3 years.

"Dr. JH07" paraphrases a quote from Forrest Gump, "'It rolls downhill', this became a reality for PCP's [primary care providers] with regard to referrals, preauthorizations of drugs and radiology studies, CMN's, care plans, letters of medical necessity, FMLA forms, scooter store forms, DMV forms, routine pre-op H&P forms on healthy patients who were to have surgery, signing orders for home care agencies to justify their care and existence, work notes, disability forms, nursing home forms..."

What can be done to reduce paperwork and the associated administration costs?

As I see it, the policy options are:

- Reduce the number of payers to one. Advocates of a single payer system argue that reduced administrative costs are one of its big advantages over the US's "pluralistic" system. A single payer would have one set of rules relating to benefits, eligibility, billing, and utilization review, unlike a pluralistic system where each insurer has its own requirements. Single payer systems, though, are quite capable of generating their own paperwork hassles for physicians. Consider all of the paperwork involved with traditional Medicare fee-for-service, which is "single payer" for elderly and disabled patients.

- Let physicians and patients set their own terms. Go back to the days when patients "contracted" with their physicians for services; the fee charged and the services provided were determined by the doctor and the patient. Eliminate price controls and "balance billing" limits. Provide health insurance coverage only when out-of-pocket expenses exceed a high dollar threshold (e.g. health savings accounts).

- Eliminate fee-for-service. Paperwork may be the consequence of paying doctors based on the volume of visits and procedures. Pre-authorization and retrospective utilization review, medical necessity and DME authorization forms, coding and documentation requirements - all these (and more) are designed to control "inappropriate" utilization. Paying doctors on a "bundled" or capitation basis, linked to measures of performance, could reduce the need to second-guess physicians' decisions. But physicians have been reluctant to embrace bundled payment systems and the associated financial risk it places on them.

- Standardize and simplify. Get insurers to agree to uniform credentialing, eligibility, billing and transaction systems, or require them to do so. Substitute retroactive claims review with "real time" claims adjudication. Go after and eliminate specific paperwork that does not make sense. (How about submitting insurers' utilization review to the evidence-based standards of effectiveness demanded of physicians?) It seems, though, that every time progress is made in eliminating one silly rule, another one crops up to take its place.

- Use technology. Imagine if every patient had a "smart card" that included their insurance eligibility, co-payments, deductibles, and covered benefits that could be "read" by every doctor's office? Or if all insurance transactions were billed electronically using a common platform? Or if interoperable and standardized health information technology allowed physicians, hospitals, and laboratories to seamlessly share patient information with each other, linked to patients' own personal health records?

The first two options - single payer or letting physicians and patients set their own terms - have strong proponents within the medical profession, but in my view are the least likely to be accepted by policymakers. More likely, a policy to reduce paperwork will involve alternatives to fee-for-service, standardization of insurance transactions, and health information technology.

Today's questions: Which of the above approaches do you believe would be most and least effective in reducing paperwork? Are there other options that should be entertained?

Wednesday, November 19, 2008

Woody Allen once said, "More than any other time in history, mankind is at a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let's pray we have the wisdom to choose correctly."

Replace mankind with primary care and you get a good idea of how primary care doctors view their future. At least, this is the conclusion one would draw from a survey of 12,000 (mostly primary care) physicians released by the Physicians' Foundation:

- 78% believe there is a shortage of primary care doctors in the United States today.- 49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.- 60% would not recommend medicine as a career to young people.

Other surveys show less pessimism. The Center for Studying Health System Change found that 83.6% of primary care physicians surveyed in 2004-2005 said they were somewhat or very satisfied with their careers, only marginally less than the 84.7% of specialists who said the same. (A new CSHSC survey is in the field, and it will be interesting to see if primary care physicians have grown more dissatisfied).

Still, the Physicians' Foundation survey is a wake up call. Think of the impact on access if half of the primary care physicians in the U.S. reduce the number of patients they see or stop practicing.

It may be a mistake, though, to suggest that primary care is all about gloom and doom. I don't discount the very real concerns, but do we really want to tell young doctors and medical students that primary care is a dying field?

Today, the American College of Physicians releases a new white paper to make the case for primary care. The report doesn't mince any words about the dire circumstances surrounding primary care, but makes the positive case that primary care will improve outcomes and lower the costs of care.

Will policymakers listen? Last week, Senator Baucus aptly called primary care the "keystone" of a high performing health care system and proposed to increase Medicare payment to primary care doctors. During the campaign, President-elect Obama proposed "to expand funding - including loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions" for primary care.

Today may be the worst of times for primary care, but the best of times could still be ahead.

I say this not because I am hopelessly optimistic (I work in Washington, after all), but because I believe policymakers can be shown that primary care offers the best value in U.S. health care. Policies to support primary care will follow suit. Isn't this a better message to give medical students and young doctors than (only) telling them how bad things are?

Today's questions: Do you believe that this is the worst of times for primary care? Do you believe that the best of times for primary care could still be ahead?

Tuesday, November 18, 2008

When the Kaiser Family Foundation asked voters to name the top health care issue that they wanted the candidates to discuss, affordability came out as number one in its October poll. By affordability, the voters meant how they are paying for health care and health insurance.

It shouldn't come as any surprise that voters are concerned about affordability. Victoria Knight, writing in theWall Street Journal's blog, observes that the health insurance tab is creeping toward half of family income. Susan Block reports in USA Today that the average employee's health care costs, including premiums and out-of-pocket expenses, will increase 8.9% in 2009, far outstripping wage increases and overall inflation.

Making health care affordable to individuals and families should be a goal of health care reform. But health care also needs to be affordable to the country as a whole - that is, the nation has to be able to produce enough wealth to sustain a given level of health care spending, which is not the same thing as personal affordability.

On this score, the public is unconcerned. The same Kaiser tracking poll found that only 6% of voters identified "reducing the total amount the country spends on health care" and only 7% cited "reducing spending on government programs like Medicare/Medicaid" as issues that the candidates should address.

In my mind, reducing (or at least limiting the rate of increase) in health care spending is the central issue. One could envision reforms that on paper make health care affordable to individuals, such as by capping out-of-pockets costs or premiums, but bankrupt the country in the process. In reality, the only effective way to make health care affordable is to lower health care spending.

The problem is that controlling health care costs will require trade-offs that the public seems disinclined to consider, such as restrictions on access to tests or procedures of uncertain value.

Let's not blame the voters though. Politicians haven't been profiles in courage in explaining why the country needs to reduce health care spending, and how. Nor have stakeholders - hospitals, health plans, unions, drug companies, device manufacturers, and yes, organized medicine - been rushing to say what they're willing to give up to lower spending. (Each is pretty good though at pointing out how someone else should cut their spending.)

Today's questions: What do you think can be done to make health care affordable - not only to individuals, but the country as a whole? What should physicians be willing to give to help cut spending?

Monday, November 17, 2008

The post-election discussion of health care reform has been focused on what the new president and Congress will do. In the shadows, though, are an unelected few with enormous influence over the outcome. Presidents and lawmakers defer to them. Get their blessing, and legislation moves forward. Earn their disapproval, and legislation stalls.

No, I am not talking about a hidden cartel of Washington insiders that secretly pull the strings. The people I am talking about work for our elected lawmakers.

The Congressional Budget Office (CBO) is a non-partisan agency, created by Congress to provide non-partisan advice on federal budget policy. One of its roles is to provide estimates to Congress on the cost (to the federal government) of proposed laws.

This is how the process works:

Proposed legislation is sent to the CBO for a "score". A "favorable score" means that CBO decides that the law will save the government more than it will cost. An "unfavorable score" means that CBO decides that the bill will cost the government more than it saves. The CBO score matters, because under "pay as you go" rules created by Congress, higher spending on entitlement programs, like Medicare, must be offset by cuts or "revenue increases" (taxes) somewhere else.

(By now, you are probably thinking that I am getting into some really arcane Washington insider stuff, but stay with me.)

The CBO was created for good reason. Members of Congress know that they can't trust themselves to honestly predict the costs of bills in which they have a vested stake. The problem is that CBO's influence is so great that good ideas often do not go forward if they receive an unfavorable score.

For example, say a member of Congress introduces legislation to increase Medicare payments to primary care physicians. If the CBO concludes that paying more for primary care will save the government more than it costs, the bill would get a favorable score and move forward. But if the CBO conservatively calculates that paying primary care doctors more will increase Medicare expenditures, the legislation will likely stall - unless Congress finds budget "offsets", such as cutting fees paid to non-primary care physicians, to pay for it (easier said than done).

The same would be true of proposals to expand coverage or make other improvements in health care delivery.

David Kendall of the Progressive Policy Institute writes that CBO's "conservative" approach to budget scoring could stymie health care reform, because CBO will be reluctant to count savings from changes in health care delivery. Without "score-able" savings from delivery system reform, there may not be enough money to cover the uninsured. As an alternative, Kendall suggests that CBO first projects the high health care spending that will occur without any delivery system reform and "if the savings from reform exceed the projections, the extra funds can be automatically applied to coverage for the uninsured."

This "It's a Wonderful Life" approach to budget scoring makes eminent sense. It wouldn't require that advocates of delivery system reform prove to the CBO that changes will lower federal spending; only that federal spending would be higher without them. It would, for instance, allow ACP to make the case to CBO that health care spending will be higher if reforms aren't enacted to increase the numbers of primary care physicians.

This is precisely what ACP plans to do. On Wednesday, we are releasing a new white paper, How is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?, that makes the case that without primary care, costs will be higher and the quality of care lower. I will write more about this paper on Wednesday's blog post.

Today's questions: From your own experiences, do you think that health care spending will be higher if something isn't done to reverse the decline in the numbers of primary care physicians? Why or why not?

Friday, November 14, 2008

Writing a blog at 34,000 feet, on a flight to Dallas going through an unusual bout of turbulence, is a rather disconcerting experience. The captain advises us that there is "no good air" at any elevation except 16,000 feet, but then says flying at the lower altitude would burn fuel at twice the usual rate - so we'd never get there. (He means to be reassuring, but I don't think the words "never get there" are ones that a captain should ever utter to nervous passengers!)

This reminds me of the turbulence in the U.S. health care system. We are looking to the new captain in Washington - Barack Obama - to guide us to calmer circumstances. But the U.S. health care system is burning its fuel - the dollars that businesses, government, and individuals are paying into health care - at a rate that can't be sustained.

The airplane analogy only goes so far. Our captain knew from years of experience how to get us through the bumps.

But, no president has experience with the degree of turbulence that is now unfolding in the U.S. health care system, the U.S. economy, and world financial markets.

Instead of thinking of President-elect Obama as the steady airline captain who relies on experience to guide passengers to the calm he knows is ahead, we should instead look at him as an engineer who is trying to redesign a broken heath care system before it crashes and burns.

He can't do it alone. He will have to rely on the advice and support of many to reform a health care system that costs too much, covers too few, delivers less than optimal quality, and has too few primary care doctors.

The American College of Physicians (ACP) is providing President-elect Obama and members of Congress with our ideas on building a better health care system. Earlier this year, ACP published a position paper in the Annals of Internal Medicinethat compares U.S. health care to the experiences in other countries and draws lessons to guide U.S. health care policy. One of those lessons is that all high performing health care systems are based on a strong foundation of primary care, a topic that John Iglehardt writes about in today's Health Affairs blog. We also found that all effective health care systems in other countries guarantee, by law, that all residents have access to affordable coverage.

We just recently updated ACP's own proposal, called our seven year plan, on how to create a pathway to universal coverage that builds upon our current employer-based system. Next week, we will be releasing a new white paper that summarizes over 100 studies that shows that the availability of primary care is consistently associated with better outcomes and lower costs.

We also need your ideas. In each of my blog posts, I will continue to ask you for your comments on how to improve the health care system. (Thanks to the many of you who have submitted thoughtful comments on prior postings.)

Today's question: if there was a single piece of advice that you would want to give to President-elect Obama on how to steer the U.S. health care system out of turbulent times, what would it be?

Thursday, November 13, 2008

Yesterday, Senator Max Baucus, chair of the Senate Finance Committee, released his plan for reforming U.S. health care. The plan offers a road map for expanding health insurance coverage and improving health care delivery--with a strong emphasis on primary care, which he calls the "keystone of a high performing health care system."

He offers several specific ideas to strengthen primary care:

* A process would be created to reduce payments for services found to be overvalued under the Medicare physician fee schedule and redistribute them to increase payments for undervalued primary care services. The paper implies that this review would take place outside the usual RVS Update Committee (RUC) process.* Medicare payments for evaluation and management services furnished by primary care practitioners would be increased. Congress would mandate a process for identifying which specific services would qualify for the increase and criteria for determining if a practitioner is truly focused on primary care.* Medicare's testing of the Patient-Centered Medical Home would be expanded to include more practices that are able to demonstrate that "patients truly receive the primary care and care management services that the medical home is designed to deliver."* The Medicare sustainable growth rate (SGR) formula might be replaced with multiple expenditure targets based on sub-sets of services. The paper suggests that separate targets have the advantage of "reallocating resources from high-growth, potentially overpaid aspects of health care to underutilized, potentially more valuable services such as primary care and prevention."

The changes in physician payment will be budget neutral, meaning "that any increase to primary care providers requires a corresponding cut to specialist services." The paper acknowledges that such redistribution "has the potential to create significant controversy among physicians."

No kidding. Every effort over the past twenty years to increase payments for primary care has created enormous controversy within medicine.

Senator Baucus' paper is a powerful statement that primary care has arrived as a top concern of policymakers. But the question of "who will pay for primary care?" remains a central challenge.

Today's questions: Do you agree with Senator Baucus that primary care is the "keystone" of a high performing health care system and needs to be supported with higher fees, even if that means taking money from other specialists, including some internists? If you don't believe specialists' fees should be cut, then how would you recommend Senator Baucus and his colleagues pay for higher primary care payments--if at all?

Wednesday, November 12, 2008

Another lesson from President Bill Clinton's unsuccessful effort to reform health care is that Congress needs to be involved from the beginning. The Clinton administration developed a complex bill behind closed doors and then sent it to Congress, expecting that Congress would get behind the administration's proposal. The proposal died for many reasons, but one was that key members of Congress - the chairs of the congressional committees with jurisdiction over health care - were left out.

Members of Congress are determined not to let this happen again. Early indications today are that the Obama administration may be willing to defer to Congress on the development of legislation, as long as it meets the new President's key principles and priorities.

Today, Senator Max Baucus, Democrat from Montana, released an executive summary and detailed paper on his approach to health care reform legislation (FYI the complete document is over 100 pages so readers may think twice before downloading it). His views are critically important, because he chairs the Senate committee with jurisdiction over tax legislation, Medicare, Medicaid, and SCHIP.

I will provide more commentary on the Baucus plan tomorrow. Of interest, the proposal emphasizes the need to provide coverage to all Americans, to guarantee access to preventive services, and to strengthen primary care and chronic care management. Senator Baucus calls primary care "the keystone of a high performing health system."

Tuesday, November 11, 2008

Politicians would like to duck this question, of course, because the politics of requiring someone to pay more, especially if they are paying more so someone else can get care, are tough.

Realistically, the options come down to these:-Increase taxes-Require that employers provide coverage to their employees or pay a penalty-Require that individuals buy coverage, if they are able to afford it-Require that individuals contribute a share of the cost through higher premiums and cost-sharing, which could be income-based-Pass the costs onto future taxpayers by borrowing the money and driving up the deficit.

It likely will end up being a combination of these options.

During the campaign, President-elect Obama proposed to pay for his health care proposal by repealing some of the Bush tax cuts for people with incomes above $250,000; to require "larger" employers to "pay or play"; and to mandate that parents buy coverage for their kids. Although he argued that his plan pays for itself this, this assumes cost savings from reforms, like prevention and health information technology, that may not add up in the end.

As controversial as the "who pays" issue will be, the current method of financing health care, which is largely through employee and employer contributions administered through direct contributions and deductions from wages, probably cannot be sustained.

Economist Uwe Reinhardt writes that rising health care costs will soon swamp the wages of many workers. He writes that for a family who today has an assumed gross wage base of $60,000, that gross wage might grow by 3 percent per year over the next decade, to $80,600 by 2017, while total family health spending might grow by, say, 8 percent per year over the same time frame, to $33,700 by 2017. For this worker, 41 percent of the family's gross wage base would be taken up by health care alone, before any deductions for taxes or fringe benefits.

His conclusion:"Before long the gross wage base earned by American households will become too small a donkey to carry the load of the family's spending on health care."

This, he says, will leave the country with only two unpalatable choices: require higher income workers to pay more, or have a two tiered system where the well off get a rich package of benefits and lower wage workers get only "bare-bones" health care.

Today's questions: How do you think that affordable coverage for all can be paid for? Should higher income persons be required to pay more?

Monday, November 10, 2008

Jeff Goldsmith, writing for the Health Affairs blog, proposes three health care reform scenarios that the Obama administration could pursue. One of his scenarios is to start out by laying the groundwork for improving health care delivery and putting off more controversial and costly coverage decisions to a later day:

"Obama could move aggressively and quickly to expand primary care physician payment under Medicare (through a version of the Medical Home idea), double federal funding for community health centers, and create a medical student loan forgiveness program for students entering geriatrics and primary care specialties ..."

I share Mr. Goldsmith's view that policies to rebuild the physician primary care workforce must be part of health care reform. As the Commonwealth of Massachusetts has found, giving people health coverage does not ensure access to care if there aren't enough primary care doctors around to take care of them. I am uncomfortable, though, with Mr. Goldsmith's suggestion that health coverage might be put off to another day, since primary care and health coverage are two sides of the same access coin.

Expanding and improving primary care physician payment will itself be controversial. I am writing this blog from the American Medical Association's House of Delegates meeting, where primary care and medical homes are both major topics being discussed. Many of the physicians lining up at the microphones have expressed support for primary care - as long as it doesn't involve redistribution of dollars among physicians.

It is not a good sign that some physician specialty societies already are drawing such lines in the sand.

From a political (and maybe a policy) standpoint, it would be less controversial if an Obama administration found a way to improve payments for primary care physicians without taking money from other doctors. The administration could find that there is sufficient data to conclude that higher payments for primary care and the medical home will pay for itself by reducing preventable hospital admissions paid under Medicare Part A. A portion of such Part A anticipated savings could then be used to raise primary care payments.

But what if the Congressional Budget Office isn't persuaded that primary care will pay for itself through savings in Medicare Part A? Where then will the money for primary care come from? Or what if President Obama and Congress decide that higher paid specialties should as a matter of policy and fairness give up something to raise payments for primary care?

The choice could come down to doing nothing to help primary care, or paying for primary care at least in part by redistributing dollars from higher paid specialists.

I would like to hear the views of Internal Medicine generalists and IM subpsecialists (and even from surgeons who might read this blog) on the following:

Should higher paid physician specialties be asked to give up something to increase payments for primary care? If not, then where should the money come from? Should ACP support reforms to improve payments for primary care - even if this will result in reduced payments to some IM subspecialists?

Friday, November 7, 2008

One reason why President Bill Clinton was unsuccessful in his effort to reform health care is that although the opposition was unified, the advocates for universal coverage were split. One reform camp was willing to support a pluralistic model, as proposed by President Clinton, as long as it included guaranteed (mandated) coverage. The other insisted that a single payer plan - often described as Medicare for all - was the only acceptable outcome.

Jacob Hacker, professor of political science and resident fellow of the Institution for Social and Policy Studies, had this to say in the May-June issue of Health Affairs:

"Born in a policy hothouse, the Clinton plan wilted in the cold winds of politics."

He argues that a successful effort this time "will require updated strategies including a greater willingness to compromise on means, yet greater clarity on ends" and "serious efforts to bring on board ... reformers who support a universal Medicare plan, to provide them with the guarantees and arguments they need to embrace a less inspiring but more politically palatable approach."

President-elect Obama's health care reform proposal builds upon existing employer-based coverage provided principally by private insurers, instead of a "Medicare for All" approach. (Click on ACP's election tool for more information about the Obama plan and how it compares to ACP policies)

ACP understands why a single payer approach is appealing to some. Based on an evidence-based review of the experiences of other countries' health systems, ACP recommended that policymakers consider one or the other of two pathways to achieve universal coverage: a single payer financing model or a pluralistic model with coverage guaranteed by law. The paper notes that either have significant advantages and disadvantages that would need to be considered, but both are preferable to status quo of pluralism without universality.

The political reality, though, is that President Obama will not ask Congress to enact a single payer plan.

Today's questions: Will the "Medicare for all" camp be behind the Obama approach, even though it may be the "less inspiring but more politically palatable approach?" Or, will they hold out for a day when the political environment might allow for a single payer plan - at the risk of losing any chance for reform now?

Thursday, November 6, 2008

In the closing moments of the 1992 movie The Candidate, Senator-elect McKay, played by Robert Redford, turns to his top political advisor and anxiously asks "What do we do now?" as throngs of journalists pour into his hotel room. He never receives an answer.

The same question must be going through the minds of President-elect Obama and his transition team. The President-elect must organize his administration and decide on his priorities for the first 100 days.

One of the lessons from President Bill Clinton's failed attempts to reform health care is that it must be a top legislative priority from the very beginning. The Clintons waited months before unveiling their health care reform plan, and the delay allowed their precious political capital to be consumed by other issues.

Just four days before the election, CNN's Wolf Blitzer asked Senator Obama to rank his priorities. Senator Obama named stabilizing the economy as the top priority. "We don't know yet what's going to happen in January," Obama said. "None of this can be accomplished if we continue to see a potential meltdown in the banking system and financial system. So that's priority No. 1: making sure the plumbing works." (Could this be a job for Joe the Plumber???)

Senator Obama's priority number two was energy independence; priority number three was health care reform; tax reform/tax cuts was number four; and improving education was fifth. After naming health care reform as third, Senator Obama said this:

"I think the time is right to do it."

Voters agree. The New Health Dialogue Blog reports that a "a stunning two-thirds [of voters] expressed concern about affording health care" in exit polls taken on Tuesday and that "62 percent of respondents in that latest Kaiser tracking poll stated 'it is more important than ever to take on health care reform.' " (According to Drew Altman of the Kaiser Family Foundation, exit polls are a good indicator of whether voters have sent a message to politicians that is strong enough to create a mandate to reform health care).

The question of "What do we do now" can also be asked of health care reform advocates, like the American College of Physicians, who agree that the time is right. Just because a new President wants to reform health care doesn't mean it will happen. ACP needs to do its part so the opportunity to reform health care does not once again pass the country by.

In January, we released a candidate's pledge that described how ACP felt the candidates should shape their health care proposals, based on the College's key health reform priorities. ACP's election tool has been updated to show how President-elect Obama's positions compare to ACP's policies and priorities. Links are given to additional resources to learn more about the Obama plan.

Today's questions: Do you agree that the "time is right" to reform health care? How should ACP answer the question of "what do we do now?" to bring about health care reform?

Wednesday, November 5, 2008

There is one word in my mind that best describes the 2008 election: extraordinary.

And, I say this from a purely non-partisan standpoint. Whether one voted for Senator Obama or Senator McCain, it is undeniable that the outcome of this election is extraordinary.

That the voters elected the first African American to the Presidency of the United States is in itself an extraordinary occurrence. I will leave it to others more eloquent than me to describe what this means for the country.

Instead, I will focus on the extraordinary re-alignment of political power in Washington created by this election, and what it may mean for health care.

President-elect Barack Obama is the first Democrat to get more than 50% of the vote since Jimmy Carter. He scored the biggest Electoral College victory since Bill Clinton in 1996. He won in parts of the country - the South, the Midwest, and the Mountain states - that in the past two presidential elections were out of reach for Democratic candidates. He is the first Senator to be elected President since John F. Kennedy.

He has the political fortune of being able to work with a Congress where both chambers are controlled by his own political party. When all the votes are counted, it looks like the Democrats will gain another 20 or so seats in the House of Representatives, and another 5 to 7 seats in the Senate, leaving them just a few votes short of the 60 votes needed to overcome Senate filibusters. President Bill Clinton had similar congressional majorities in his first two years, but came to office with the decided disadvantage of having won only a plurality (43%) of the total votes cast in the election.

Few presidents have had as great an opportunity to shape the nation's politics, priorities, and policies at a time when the country is facing so many crises, both domestically and abroad.

One priority will be health care reform. Health care reform is the holy grail of the Democrats. From Harry Truman to Bill Clinton, Democratic presidents have sought to achieve universal coverage, only to find the politics and policies too difficult.

Will an Obama administration be any different? Some observers speculate that an Obama administration will back away from health care reform, because it costs too much, the deficit is too high, and there are too many competing priorities.

I disagree: President Obama and the congressional leadership will not allow the best chance in a generation to achieve lasting health care reform to pass them by.

I expect the new president and the leadership of Congress to make a push early in 2009 for comprehensive reforms to expand coverage - starting with reauthorization and expansion of the State Children's Health Insurance Program (SCHIP), which expires on March 31 - and then moving beyond that to try to enact income-based subsidies and insurance market reforms to close gaps in employer-based coverage. They will also take on Medicare physician payment reform.

Will they succeed? That depends largely on whether President-elect Obama and his congressional allies have learned the lessons from the last time the country had a serious debate over health care reform. Over the next few days I will post and invite commentary on some of those lessons, and the extraordinary opportunities and challenges health care reform poses for the American College of Physicians.

Today's question: What do you believe the 2008 election means for health care?

Tuesday, November 4, 2008

In a landmark 2007 study, ACP members David Grande, David Asch and Katrina Armstrong found that "Physicians have lower adjusted voting rates than lawyers and the general population, suggesting reduced civic participation," and that this dates back to the late 1970's (Do doctors vote? JGIM. 2007; 22: 585-9).

The authors speculate that "physicians may view their clinical work as having a greater social purpose [than voting]. As a result, civic participation might appear less important. Voting in particular may be viewed as trivial relative to the significance of physicians' daily clinical encounters."

The Physicians' Charter on Professionalism endorsed by the ACP, states that civic engagement is integral to professionalism. "Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession." [Emphasis added].

Public advocacy can involve many things, but in my mind it starts with voting.

It is understandable that some busy internists, faced with a choice between spending hours in line to vote, or devoting the same time to encounters with patients, might choose the clinical encounter over voting.

But as Drs. Grande, Asch, and Armstrong put it, "the U.S. health care system is widely recognized as plagued with major problems, including the intractable number of uninsured and thousands of associated deaths . . . As members of a profession, physicians should be participating in public affairs and contributing solutions."

I encourage our physician readers to show up at the polls today. You can help make 2008 the year that the medical profession participates in the voting process, at least to the same degree as your patients.

Today's questions: Did you vote today? Why or why not?

Tomorrow: my initial thoughts on what the election results mean for health care.

Monday, November 3, 2008

By the end of the day tomorrow, we should know who will be the new President of the United States come January 20th. We should also have a pretty good idea of how many seats the Democrats and Republicans will gain or lose in the new Congress.

How will we know, though, if the election produced a voter mandate for health care reform?

I will post some preliminary thoughts on Wednesday. It is likely, though, that it will be weeks, even months, before we know how the new President views his mandate.

Still, there are things you can be looking for tomorrow.

Drew Altman from the Kaiser Family Foundation describes the four stages of what he calls "the critical path to health reform." The first stage is the general election, for which he poses two questions:

1. Was there "a big debate on health care" that elevates the issue and engages the public?2. If there was a big debate, do the exit polls show health care was a voting issue, sending a message to politicians that is strong enough to create a mandate?

In my view, the answer to the first question is a guarded yes. Health care reform was a major issue debated by Senators McCain and Obama. The candidates presented voters with radically different views on how to move forward.

How engaged the voters were, though, is less clear. Kaiser's own October health care tracking poll found that "the rising tsunami of economic problems swamped health care and every other issue to dominate the agenda in the weeks before the November vote. Health care remains roughly tied for second, but this ranking is somewhat misleading: it is 50 percentage points lower than the economy, as is the other former top tier issue -- Iraq."

So tomorrow, look at what the exit polls tell us about health care. Then stay tuned for the next stage in Dr. Altman's path: the new President, and whether he makes health care a priority and exercises leadership on this issue.

As the votes come in on Tuesday, post your comments on what you think the election means for health care reform. (But please, no partisan attacks on the candidate you don't like!)